Class of 2009 Abstract / OBJECTIVES: To determine patient preference for the type of visit for the receipt of the influenza vaccine from the pharmacist and to determine patient preference for contact method for annual notification of the influenza vaccine program. METHODS: This was a descriptive study using a short telephone survey. The first dependent variable was the preferred type of visit comparing appointment-based and predetermined walk-in clinics. The second dependent variable was the preferred method of contact for annual notification of a pharmacist administered influenza vaccination program (telephone, US post mail, email). RESULTS: The telephone survey was completed by 206 patients. Overall, study participants preferred appointment-based visits ( 81.2 %; p < 0.05) compared to a predetermined walk-in clinic (18.8%). Overall, study participants significantly preferred to be contacted for annual notification of a pharmacist administered influenza vaccination program via telephone (75.7%; p< 0.05) compared with US post mail and email. Based on the percentages observed, the second preferred method of contact was email (12.6%) and US post mail was the third preferred method of contact (11.7%). CONCLUSIONS: Patient preference for type of visit for pharmacist-administered influenza vaccine was appointment-based as opposed to predetermined walk-in clinic based. Patient preference for contact method for annual notification was telephone as opposed to email or postal mail.

Background: Tooth loss has a negative impact on patients’ general health and wellbeing. Dental prostheses can restore oral function, aesthetics and improve oral health related quality of life. Preferences for dental prostheses cannot be fully captured using existing clinical studies and questionnaires. Discrete choice experiment (DCE) is a novel method in health economics to elicit people’s preference for treatments and it allows the researcher to integrate all aspects relevant to treatment into evaluation and measurement of interrelationship between factors. The aim of this PhD thesis is to use a mixed method of DCE and qualitative interviews to analyse dentists and patient’s preferences for dental prosthesis choices in replacing missing teeth. Methods: Discrete choice experiment questionnaires were developed, describing dental prosthdontic treatments in multi-dimensions, including outcome, process and economic factors. Survey and analysis using the questionnaires were conducted with dentists and patients in Edinburgh. Qualitative interviews with Edinburgh dentists and patients were carried out to derive factors to aid the DCE questionnaire design and provide in-depth understanding of DCE results. Systematic reviews were performed to summarise existing evidence on prosthesis evaluation in traditional quantitative studies and perception of prostheses in qualitative interviews. The current application of DCEs in dentistry was also systematically reviewed. Results: Treatment longevity was identified as the most important factor for dentists and patients’ treatment decisions of anterior missing tooth replacements, followed by appearance and chewing function. Dentists put more value on fixation/comfort and treatment procedure than patients. Patients cared about cost of treatment whereas dentists were relatively insensitive. Gender, age and treatment experience significantly influenced patients’ preference for treatment characteristics. Dental implant supported crown was preferred by dentists, whereas patients gave higher utility to traditional prosthodontic treatments. The monetary benefit of fixed dental prostheses ranged from £1856 -£3848 for patients, far exceeding their willingness-to-pay (WTP), which was £120 - £240. Dentists were willing to pay £600-£3000, more than the perceived benefit £503 to £1649. Qualitative study identified the above factors and provided interpretation of DCE results. Problems in the dental care system related to referral and training for dental implant treatments were raised. Discussion: This thesis is the first DCE application in dentistry evaluating and comparing dentists and patients preferences for missing tooth replacements. Dentists and patients’ preferences were elicited qualitatively and qualitatively integrating multidimensional factors. Patients’ preference for treatments, monetary benefit and WTP were demonstrated to be different from dentists’. Treatment benefits exceeded patients WTP for fixed dental prostheses.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Apesar dos avanÃos da ciÃncia, o medo e ansiedade, por razÃes odontolÃgicas, ainda acometem uma grande quantidade de pessoas, comprometendo a procura por tratamento e resultando, ocasionalmente, em baixos nÃveis de saÃde oral. A aparÃncia fÃsica dos instrumentos parece ser um dos principais causadores de medo e ansiedade no meio odontolÃgico, e a seringa anestÃsica à o instrumental que mais desencadeia estes sentimentos. Assim, diminuir a ansiedade e o medo do tratamento odontolÃgico deveria ser uma das prioridades do cirurgiÃo-dentista. Para tanto, a presente dissertaÃÃo teve por objetivo comparar as reaÃÃes apresentadas por crianÃas que foram anestesiadas com um dispositivo em formato lÃdico e com uma seringa tradicional, com a finalidade de analisar se uma mudanÃa no desenho externo da seringa anestÃsica seria capaz de influenciar os nÃveis de ansiedade, medo e dor dos pacientes. Sessenta e quatro crianÃas, com idade ente 4-10 anos, foram distribuÃdas aleatoriamente em dois grupos, de acordo com o dispositivo a ser utilizado na primeira sessÃo anestÃsica. G1 (Convencional) e G2 (Design modificado). Os participantes submeteram-se a duas sessÃes anestÃsicas, e cada paciente foi anestesiado com ambos dispositivos. Um Ãnico pesquisador, odontopediatra, realizou os procedimentos anestÃsicos que foram filmados e consistiram de anestesias terminais infiltrativas, na regiÃo posterior da maxila. Devido ao carÃter multidimensional do medo, ansiedade e dor, uma combinaÃÃo de testes foi utilizada para avaliÃ-los, como: O teste de medo da crianÃa (Child Fear Survey Schedule â Dental Subscale - CFSS-DS), escala de ansiedade facial (Facial Anxiety Scale- FAS), frequÃncia cardÃaca, escala som, olhos e movimento (Sound, Eyes and Motor-SEM), escala visual analÃga â Visual Analogue Scale (VAS) e escala Frankl. As escalas foram aplicadas em momentos predeterminados, como: sala de espera (SE), cadeira odontolÃgica (CO), inÃcio da anestesia (IA) e final da anestesia (FA). ApÃs a segunda sessÃo anestÃsica, as crianÃas escolheram o dispositivo que mais as agradou. Os resultados mostraram que 78% da amostra foi classificada como pouco ansiosa (CFSS-DS). Nenhuma diferenÃa estatisticamente significante pÃde ser observada nas diferentes escalas, ao comparar o dispositivo tradicional com o modificado. A seringa com mudanÃa no design foi a preferida por 57,8% das crianÃas. As crianÃas ansiosas relataram mais dor que as nÃo ansiosas (p=0,001) e o estado emocional variou nas diferentes situaÃÃes: SE, CO, IA e FA. (p<0,05). Assim, concluiu-se que a aparÃncia da seringa à importante, mas nÃo à fundamental no controle da ansiedade, medo e dor de crianÃas submetidas à anestesia odontolÃgica. / Despite advances in Odontology, fear and anxiety regarding dentistry still affect a large number of people who, because of their fears, fail to seek treatment; this can result in low levels of oral health. The physical appearance of the instruments used by dentists seems to be a major cause of such fear and anxiety with regard to dentistry. The anesthetic syringe is the instrument that causes the strongest feelings of fear. So, the prevention of dental anxiety and patients fear should be one of the dentistâs highest priorities, this study aims to compare the reactions shown when children were anesthetized with a modified device and when they were anesthetized with a traditional syringe, and examine the results to see if a change in the external design of the anesthetic syringe can influence the levels of anxiety, fear and pain of patients. Sixty-four children aged 4-10 years were randomly assigned into two groups according to the device to be used in the first session of anesthesia. G1 (Traditional Syringe) and G2 (Modified syringe). Participants underwent two sessions and each patient was anesthetized with both devices. A single researcher performed anesthetic procedures, which were videotaped and the procedure consisted of infiltrative anesthesia in the posterior area of the maxilla. Due to the multidimensional nature of fear, anxiety and pain, a combination of tests was used to access them: Child Fear Survey Schedule - Dental Subscale - CFSS-DS, Facial Anxiety Scale-FAS, heart rate, the SEM scale Sound, Eyes and Motor, the Visual Analogue Scale (VAS) and the Frankl scale. These tests were applied in predefined situations as the waiting room (WR), the dental chair (DC), during the onset of anesthesia (OA) and end of anesthesia (EA). After the second session of anesthesia, children chose the device that they preferred. The results showed that most 78% children were classified as having a low level of anxiety (CFSS-DS). No significant difference was observed when comparing the traditional and modified devices. The syringe with a change in design was preferred by (57.8%) of the children. The anxious children reported more pain than non-anxious (p = 0.001) and their emotional state varied in different situations: WR, DC, OA and EA. (P <0.05). Thus, it was concluded that the appearance of the syringe is important, but not essential in order to control the anxiety, fear and pain which children suffer when undergoing dental anesthesia.

BACKGROUND: Parents of children with juvenile idiopathic arthritis (JIA) are often forced to make trade-offs between the effectiveness, convenience, safety, and cost of drug treatments for their child. METHODS: A discrete choice experiment was administered to parents of children with JIA to determine their preferences for drug treatments. Multinomial logit regression was used to estimate part-worth utilities and willingness-to-pay. RESULTS: Participation in daily activities was the most important attribute, followed by child reported pain. Child age, gender, years with JIA, and household income had the greatest impact on preferences. Parents’ were willing to pay $2,080 to switch from a drug representing methotrexate to etanercept (95% CI $698, $4,065). CONCLUSIONS: Parents of children with JIA have the highest maximum willingness-to-pay for drug treatments that improve daily functioning and reduce pain. Cost is a significant factor in the decisions that parents make surrounding the best treatment for a child.

BACKGROUND: Parents of children with juvenile idiopathic arthritis (JIA) are often forced to make trade-offs between the effectiveness, convenience, safety, and cost of drug treatments for their child. METHODS: A discrete choice experiment was administered to parents of children with JIA to determine their preferences for drug treatments. Multinomial logit regression was used to estimate part-worth utilities and willingness-to-pay. RESULTS: Participation in daily activities was the most important attribute, followed by child reported pain. Child age, gender, years with JIA, and household income had the greatest impact on preferences. Parents’ were willing to pay $2,080 to switch from a drug representing methotrexate to etanercept (95% CI $698, $4,065). CONCLUSIONS: Parents of children with JIA have the highest maximum willingness-to-pay for drug treatments that improve daily functioning and reduce pain. Cost is a significant factor in the decisions that parents make surrounding the best treatment for a child.

Det krävs planering för tid, ekonomi och andra resurser när det kommer till sjukvård. För att sjukvård ska fungera behövs det olika verktyg och hjälpmedel. Dessa verktyg och hjälpmedel är till för att ta reda på vilka patienter som ska prioriteras och vilka behandlingar som ska finansieras. Detta görs genom att undersöka exempelvis hur stor skillnad det är på kvalité och kostnad mellan olika behandlingar. Kostnadseffektanalys är ett verktyg som används för att mäta de övergripande hälsofördelarna av behandlingar, med hänsyn till deras kostnader. Det finns olika mätverktyg för att ta reda på vilka behandlingar som bör finansieras och ett av de verktygen är QALY (kvalitetsjusterande levnadsår), där vi kombinerar livslängden och livskvaliteten. Många har kritiserat QALY eftersom de menar att ramverket av QALY leder till diskriminering av patienter med funktionsnedsättning. Dock anser Whitehurst och Engel att diskriminering uppkommer av frågeformuläret som används och inte av ramverket. Frågeformulär används inom forskning och sjukvård för att ta reda på hur patienter värderar sitt hälsotillstånd med hjälp av kryssfrågor om deras psykiska och fysiska mående. Utifrån det jag har läst visar det sig trots att frågeformulären behöver förbättras inom vissa avseenden att problemet ligger på QALY som ramverk. En av kritikerna, Sean Sinclair, anser att vi bör använda oss av patient preference theory om vi vill minska risken för diskriminering av patienter med funktionsnedsättning.  Enligt Sinclair diskriminerar standard QALY- ramverket dem som har funktionsnedsättningar. Detta gäller oavsett om vi använder oss av undersökningar som frågar endast/huvudsakligen personer med funktionsnedsättning eller allmänheten. Sinclair anser att problemet bäst löses genom att göra en strukturell förändring av hur vi värderar hälsotillståndet hos patienter med funktionsnedsättningar med hjälp av ett nytt, relativiserat ramverk. Jag kommer att visa att Sinclair har rätt i att diskriminering av patienter med funktionsnedsättning kan förekomma oavsett hur vi justerar frågeformulären eller vem vi frågar. Men även som Sinclair föreslår, borde sjukvården använda sig av patient preference theory och inte av standard QALY på grund av att oavsett om frågeformuläret förbättras så kommer det fortfarande uppstå diskriminering av människor med funktionsnedsättning.

Purpose: To understand guardian and child preferences for the appearance of their pediatric dentist. This was a cross-sectional descriptive study using survey methodology with patients and parents that attended the VCU Pediatric Dental clinic. Methods: A total sample of 100 guardians and 97 pediatric patient participants completed the computer-based questionnaire. Four subjects were asked to pose for photographs wearing various combinations of attire (professional, casual, white coat, scrubs). Results: Among guardians, 56% reported preferring a provider in scrubs, with white coat the second most preferred attire (39%) for their children. For pediatric patients, scrubs were still most often selected, but at a lower rate (43%). White coat remained the second most preferred option at 37%. Conclusions: Children and parents have strong perceptions and preferences regarding their dentists’ attire. The results of this study can be used, by providers, to improve the comfort, and acceptance of care by patients and guardians.

There are no large-scale outcome studies of music therapy in secure hospital settings for people who have committed serious offences. These patients have a right to expect evidence-based multi-disciplinary treatment (Duggan et al. 2006); NICE (2010). Music therapy therefore should take a form which can be integrated into the treatment pathway. A single site implementation of a mixed-methods patient preference randomised controlled trial investigated the clinical effectiveness of a manualised music therapy model called Group Cognitive Analytic Music Therapy (G-CAMT). This context-specific, time limited intervention incorporates theories from Group Analysis (Foulkes 1964) and Cognitive Analytic Therapy (Ryle and Kerr 2003). The central research question was ‘Is G-CAMT feasible and effective for offenders in a secure multi-disciplinary treatment setting?’ The research process followed the Medical Research Council framework for developing and evaluating complex interventions (Campbell et al. 2000, 2007). Twenty patients were recruited; those expressing no preference were randomised to treatment or control arms. The two music therapists and the principal investigator were masked to their allocation status. Those in the treatment arm were allocated to one of two treatment groups of five, each run individually by one of the music therapists. Each group had sixteen ninety minute weekly sessions with followup at eight weeks. Treatment and control groups received standard care. The primary measure was the Person’s Relating to Others Questionnaire (Birtchnell and Evans 2004) Secondary measures were the Basic Empathy Scale (Jolliffe and Farrington 2006a), The Multi-Scale Dissociation Inventory (Briere, 2002) and an observational measure, the Chart of Interpersonal Reactions in Closed Living Environments (Blackburn and Glasgow, 1993). Quantitative data from these measures were examined for associations with qualitative data from semi-structured interviews administered to the music therapists and analyzed using Interpretative Phenomenological Analysis (Smith et.al. 2009) Findings from the results of the primary measure demonstrated statistically significant (Mann Whitney U: p<.05) reductions in favour of the treatment group compared to the control, in intrusive, restrictive and possessive behaviors and helpless or self-denigrating behaviours. There were improvements over time within the treatment group in the domains of sociability and hostility (Friedman Test :p<.04). The use of a manual was shown to help the music therapists manage the risk of violence without constraining their creativity. Two years after the end of the treatment 78% of treatment participants had moved to conditions of lower security over a mean period of 19 months compared with 66% of control subjects over a mean period of 25.5 months. The thesis concludes by situating G-CAMT amongst contemporary music therapy models.

Purpose: To evaluate the factors that influence potential orthodontic patients choosing between an orthodontist, general dentist, and direct-to-consumer (DTC) aligners for their treatment, and to determine the demand for each provider type. Methods: An electronic survey was administered to 250 individuals among the general population of adults in the United States. Questions were designed to determine the respondent’s level of interest in pursuing orthodontic treatment with each provider type, evaluate their current level of knowledge concerning provider options, and identify factors influencing their selection. Pearson’s chi-squared test and ANOVA were used to evaluate the factors influencing patients in their selection. Results: When asked their preference in provider type, 43.8% of respondents selected orthodontist, 34.1% selected DTC aligners, and 22.1% selected general dentist. Among respondents with the highest level of interest in pursuing orthodontic treatment, 50% selected an orthodontist and 27% selected DTC aligners. For respondents with moderate levels of interest in pursuing treatment, only 21% selected an orthodontist and 48% selected DTC aligners. The biggest perceived advantage of treatment with an orthodontist was quality of treatment, and the biggest disadvantage was cost. For DTC aligners, the biggest perceived advantage was convenience, followed by cost, and the biggest disadvantage was quality of treatment. Among adults with children, 34% selected DTC aligners for themselves and only 16% selected DTC aligners when selecting for their children. Conclusion: Adults in the United States have similar levels of interest in pursuing orthodontic treatment with orthodontists and DTC aligners and, to a lesser degree, general dentists. A significant portion of those who select DTC aligners for their treatment are patients who would not have otherwise undergone treatment with an orthodontist. Patients tend to select orthodontists due to quality of treatment, whereas DTC aligners are selected due to convenience, followed by cost. Even among parents who prefer DTC aligners for their own treatment, parents tend to select an orthodontist for their child’s treatment.

Background: Teeth affected by apical periodontitis (AP) that could be retained by root canal therapy (RCT) are increasingly being extracted and replaced with implant-supported crowns (ISC). Objectives: 1) To investigate preferences of dentists and patients towards retaining a tooth with AP using RCT versus its extraction followed by, no replacement, replacement with an ISC, or with a partial fixed or removable denture. 2) To investigate patients’ preferred role and dentists’ ethical responsibilities in decision-making. Methods: A mail-out survey (sent to: dental specialists, n=195, response rate=39%; patients, n=434, response rate=43%) and a web-based survey (general dentist sample, n=304, response rate =15%) were used to collect data. Statistical bivariate and multivariate analyses were undertaken with P set at < 0.05 with Bonferroni adjustment as necessary. Results: RCT or ISC were the most selected treatment choices for dentists, while the preference for RCT was reduced for teeth treated previously with RCT. Dentists’ preferences were associated with their specialty as well as clinical experience in endodontics and/or implant dentistry. Patients’ stated general preference for saving teeth was associated with higher self-rated oral health, frequent dental check-ups, and higher socio-demographic factors. Those with higher education, regular dental visits and previous experience of RCT preferred to undergo RCT for future treatment in comparison to those who never experienced RCT. Patients preferred a collaborative role with their dentists in making treatment decisions and valued the retention of natural teeth very highly. They also felt that communication with and trust in their dentist was paramount. Conclusion: Dentists should establish rapport with patients in a milieu that values and respects the patients’ autonomy. By following the highest standards of evidence-based care, and transferring unbiased information on treatment options and associated risks/benefits, it is highly probable that dental care will be delivered in a more ethical manner than would otherwise be possible.